Claim Form - Hospitalization
Claim Form - Hospitalization
d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
e) Address:
h) Phone No.:
I) E-mail ID:
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Policy No.: Sum Insured (`):
d) Have you been hospitalised in the last four years since inception of the contract? Yes No
Diagnosis:
a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
e) Relationship to Primary Insured: Self Spouse Child Father Mother Other (Please Specify)
f) Occupation: Service Self Employed Homemaker Student Retired Other (Please Specify)
g) Address:
(If different
from above)
h) Phone No.
i) E-mail ID:
SECTION D: DETAILS OF HOSPITALISATION:
I) If Injury, give Cause: Self Inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption
i. If Medico Legal: Yes No ii. Reported to Police: Yes No iii. MLC Report & Police FIR attached: Yes No
j) System of Medicine:
i. Pre-hospitalisation Expenses: `
v. Ambulance Charges: `
vi. Others: `
TOTAL `
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
c) Details of Lump Sum / Cash Benefit claimed:
iv. Convalescence: `
vi. Others `
TOTAL `
Others
SECTION F: DETAILS OF BILLS ENCLOSED:
4. D D M M Y Y Y Y Pharmacy Bills
5. D D M M Y Y Y Y
6. D D M M Y Y Y Y
7. D D M M Y Y Y Y
8. D D M M Y Y Y Y
9. D D M M Y Y Y Y
10. D D M M Y Y Y Y
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue
statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall
be forfeited. I also consent & authorise TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical
Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of
this claim & that I will not be making any supplementary claim except the pre / post-hospitalisation claim, if any.
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Date: D D M M Y Y Y Y Place: Signature of the Insured:
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured):
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
a) Name of Hospital where Admitted Enter the Name of Hospital Name of Hospital in full
b) Room Category Occupied Indicate the Room Category Occupied Tick the right option
c) Hospitalisation due to Indicate Reason of Hospitalisation Tick the right option
d) Date of Injury / Date Disease Enter the Relevant Date Use dd-mm-yy format
First Detected / Date of Delivery
e) Date of Admission Enter Date of Admission Use dd-mm-yy format
f) Time Enter Time of Admission Use hh:mm format
g) Date of Discharge Enter Date of Discharge Use dd-mm-yy format
h) Time Enter Time of Discharge Use hh:mm format
i) If Injury, give cause Indicate Cause of Injury Tick the right option
If Medico Legal Indicate whether Injury is Medico Legal Tick Yes or No
Reported to Police Indicate whether Police Report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC Report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the System of Medicine followed in treating the Patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the Amount claimed as Treatment Expenses In Rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalisation Indicate whether Claim is for Domiciliary Hospitalisation Tick Yes or No
c) Details of Lump Sum / Cash Benefit claimed Enter the Amount claimed as Lump Sum / Cash Benefit In Rupees (Do not enter paise values)
d) Claim Documents Submitted - Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the Amounts in Rupees
SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
a) PAN Enter the Permanent Account Number As allotted by the Income Tax Department
b) Account Number Enter the Bank Account Number As allotted by the Bank
c) Bank Name and Branch Enter the Bank Name along with the Branch Name of the Bank in full
d) Cheque / DD Payable Details Enter the Name of the Beneficiary, the Cheque / DD Name of the Individual / Organisation in full
should be made out to
e) IFSC Code Enter the IFSC Code of the Bank Branch IFSC Code of the Bank Branch in full
SECTION H - DECLARATION BY THE INSURED
Read Declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
Please return your completed claim form to:
CignaTTK Health Insurance Company Limited
OR Nearest Cigna TTK Branch.
Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063.
IRDA Registration No. 151
Call (Toll Free): 1-800-10-24462 Visit: www.cignattkinsurance.in E-mail: [email protected]
The issue of this Form is not to be taken as an admission of liability
(To be filled in Block Letters) - PART B - To be filled by Hospital
b) Hospital ID: c) Type of Hospital: Network Non Network (If non network fill section E)
e) Qualification:
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
j) Type of Admission: Emergency Planned Day Care Maternity
i. Primary Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
i. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: Yes No (If Yes, attach reports)
Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation
Hospital main bill Original death summary from hospital where applicable
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
SECTION E: ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
a) Address of
the Hospital
iii. Others:
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any
false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.
Date: D D M M Y Y Y Y
Place: Signature and Seal of the Hospital Authority:
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
c) Type of Hospital Indicate whether In network or non-network hospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along As allocated by the Medical Council of India
with the state code
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
primary diagnosis
Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional diagnosis
Co-morbidities Enter the ICD 10 Code and description of the Standard Format and Open text
co-morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the Standard Format and Open text
first procedure
Procedure 2 Enter the ICD 10 PCS and description of the Standard Format and Open text
second procedure
Procedure 3 Enter the ICD 10 PCS and description of the Standard Format and Open text
third procedure
e) If authorization by network hospital Enter reason for not obtaining pre-authorization Open text
not obtained, give reason number
If injury due to substance abuse/ Indicate whether test conducted Tick Yes or No
alcohol consumption, test conducted
to establish this
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. with State Code Enter the registration number of the doctor As allocated by the Medical Council of India
along with the state code
d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others,
please specify
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014